Sma11 4664

Substance Abuse Treatment:
Group Therapy
Inservice Training
Based on Treatment
Improvement
Protocol
TIP
41

SubstanceAbuseTreatment:
GroupTherapy
InserviceTraining
BasedonTreatment
Improvement
Protocol
TIP
41
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
1 Choke Cherry Road
Rockville, MD 20857
Acknowledgments
This training manual, based on Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment:
Group Therapy, was prepared by the Southeast Addiction Technology Transfer Center for the Substance
Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human
Services (HHS). Catherine D. Nugent, LCPC, served as the Government Project Offcer.
The manual was produced under the Knowledge Application program (KAP), contract number 270-09-0307,
a joint venture of The CDM Group, Inc., and JBS International, Inc., for SAMHSA, HHS. Christina Currier
served as the KAP Contracting Offcers Representative.
Disclaimer
The views, opinions, and content expressed herein are those of the expert panel and do not necessarily
refect the views or policies of SAMHSA or HHS. No offcial support of or endorsement by SAMHSA or HHS for
these opinions or for particular instruments, software, or resources is intended or should be inferred.
Public Domain Notice
All materials appearing in this volume except those taken directly from copyrighted sources are in the
public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source
is appreciated. However, this publication may not be reproduced or distributed for a fee without the specifc,
written authorization of the Offce of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication
This publication may be ordered from the SAMHSA Store at http://www.store.samhsa.gov. Or, please call
1-877-SAMHSA-7 (1-877-726-4727) (English and Espaol).
The document and accompanying PowerPoint slides can be downloaded from the KAP Web site at http://
www.kap.samhsa.gov.
Recommended Citation
Substance Abuse and Mental Health Administration. Substance Abuse Treatment: Group Therapy Inservice
Training. HHS Publication No. (SMA) SMA-11-4664. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2012.
Originating Office
Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for
Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry
Road, Rockville, MD 20857.
HHS Publication No. (SMA) 11-4664
Printed 2012

Contents
Training and Manual Overview. . . . . . . . . . . . . . . . . . . . . . v
Module 1: Groups and Substance Abuse Treatment . . 1-1
Module 2: Types of Groups Used in
Substance Abuse Treatment . . . . . . . . . . . . . . . . . . . . . 2-1
Module 3: Criteria for the Placement
of Clients in Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
Module 4: Group Development
and Phase-Specifc Tasks . . . . . . . . . . . . . . . . . . . . . . . . 4-1
Module 5: Stages of Treatment . . . . . . . . . . . . . . . . . . . 5-1
Module 6: Group Leadership, Concepts,
and Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
Module 7: Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
iii
v

Training and Manual
Overview
Training Purpose
This inservice training manual provides counselors and other clinical
staff members with scripted modules to use in trainings for Treatment
Improvement Protocol (TIP) 41, Substance Abuse Treatment: Group
Therapy, published by the Substance Abuse and Mental Health Services
Administrations (SAMHSAs) Center for Substance Abuse Treatment (CSAT).
The seven training modules will assist program staff in understanding and
implementing the evidence-based practices described in TIP 41.
A TIP is the end result of careful consideration of relevant research fndings
and experiences in clinical settings. For each TIP, a panel of expert clinical
researchers, clinical providers, and program administrators (the consensus
panel) discusses the issues relevant to the specifc TIP. The product of
the panel represents the combined and collaborative input of the various
viewpoints and provides recommendations for specifc best-practice
guidelines. The panels work is reviewed by expert feld reviewers. Revisions
suggested by these reviewers are incorporated into the fnal document.
TIP 41 and this training manual present an overview of the role and effcacy
of group therapy in substance abuse treatment. The goal of both documents
is to offer the latest research and clinical fndings and to distill them into
practical guidelines for group therapy leaders in the feld of substance abuse
treatment. The documents describe effective types of group therapy and
offer a theoretical basis for group therapy in the treatment of substance use
disorders. The information will be a useful guide to supervisors and trainers
of beginning counselors, as well as to experienced counselors.
Training Design
The training manual is designed as a seven-module continuing education
workshop for substance use disorder counselors and other professionals.
Senior staff members and clinical supervisors can easily lead the training
sessions.
The modules are between 45 minutes and 1 hour and 45 minutes in length.
They can be delivered as stand-alone training sessions or as elements
within a large training program. Experienced trainers are encouraged to
adjust the schedules based on external factors such as participant skill
levels, facility amenities, and other factors that affect training delivery.
Trainers should read the corresponding TIP chapters to familiarize
themselves with the full content of TIP 41 before presenting a training
module.
The primary goal of this training package is to provide a quick, easy, and
user-friendly way to deliver the content of TIP 41 to substance abuse
vi
TIP 41 Curriculum

treatment providers. The manual covers the types of groups used, criteria
for placement in a group, group development, stages of treatment, and
group leadership issues, such as leadership styles and strategies for
therapy. The trainer should be cognizant of participants needs and adapt
the material to meet these needs. Trainers notes and suggested talking
points are provided to allow fexibility.
Instructional Approach
An experienced substance abuse treatment provider should serve as the
trainer for these modules, but no training experience is required to use
the materials. The success of the training depends on the willingness of
the trainer to use the trainers notes and PowerPoint slides to enhance
discussions to ensure that participants grasp the modules objectives.
The training generally follows the fow of the TIP. The training can be
conducted in small- to medium-sized groups (1025 people).
Materials and Equipment
Each module provides trainers notes and suggested talking points.
Thumbnail copies of the PowerPoint slides that reinforce the topics are
provided in the left column. The PowerPoint slides, available at http://
www.kap.samhsa.gov/products/trainingcurriculums/index.htm, require a
personal computer; they can be saved as presentations or, if necessary,
printed to make overhead slides. The training room should be set up to
accommodate small groups and comfortable viewing of the PowerPoint
slides.
TIP 41 is used as a reference throughout the training. The trainer should
order enough copies of TIP 41 to distribute one to each participant. Copies
can be ordered free of charge from the SAMHSA Store by telephone at
1-877-SAMHSA-7 (1-877-726-4727) or electronically at http://www.store.
samhsa.gov. TIPs can also be downloaded from the Knowledge Application
Program (KAP) Web site at http://www.kap.samhsa.gov. A Quick Guide for
Clinicians based on TIP 41 can also be ordered from the SAMHSA Store or
downloaded from the KAP Web site.
References in the TIP have been deleted from the training manual. Trainers
and participants should refer to TIP 41 for original sources.
Trainers must have the following materials for all modules:
Computer
LCD projector for PowerPoint slides
Newsprint paper, easel, and colorful markers
Tape for affixing newsprint to the walls
vii
Training and Manual Overview

Manual Format
The start of each module presents the modules learning overview,
sections, and objectives. A new discussion topic or activity is designated by
a section title and the approximate time needed to complete the section.
The left column of the module page displays the following icons to assist
the trainer:
Time to complete Trainers PowerPoint
the section note slide
25 minutes
PP 7-1
Passages in Roman typeface are scripted talking points, which are based
on text taken directly from TIP 41. This text can be read verbatim or
modifed by the trainer. Text in italics typeface provides notes to the trainers
such as cues on when to begin a new section.
Learning Objectives
After completing this training, participants will be able to:
Discuss the use of group therapy in substance abuse treatment. (Module 1)
Explain five group therapy models and three specialized group therapy
models used in substance abuse treatment. (Modules 1 and 2)
Explain the advantages of group therapy. (Module 1)
Modify group therapy to treat substance abuse. (Module 1)
Explain the stages of change. (Module 2)
Match clients with substance abuse treatment groups. (Module 3)
Assess clients readiness to participate in group therapy. (Module 3)
Determine clients needs for specialized groups. (Module 3)
Distinguish differences between fixed and revolving membership groups.
(Module 4)
Prepare clients for groups. (Module 4)
Describe the tasks for each of the three phases of group development.
(Module 4)
Discuss the importance of making clinical adjustments in group therapy.
(Module 5)
viii
TIP 41 Curriculum

Explain the three stages of treatment. (Module 5)
Describe the conditions of the early, middle, and late stages of
treatment. (Module 5)
Identify leadership characteristics in the early, middle, and late stages of
treatment. (Modules 5 and 6)
Describe concepts and techniques for conducting substance abuse
treatment group therapy. (Module 6)
Identify training opportunities. (Module 7)
Appreciate the value of clinical supervision. (Module 7)
1-1

10 minutes
PP 1-1
Module 1: Groups and
Substance Abuse Treatment
Module 1 Overview
The goal of Module 1 is to provide participants with an overview of the
training and an overview of group therapy in substance abuse treatment.
The information in Module 1 covers Chapter 1 of Treatment Improvement
Protocol (TIP) 41, Substance Abuse Treatment: Group Therapy. This module
takes 1 hour to complete and is divided into three sections:
Welcome, Training Objectives, and Ground Rules (10 minutes)
Presentation: Overview of Groups in Substance Abuse Treatment (45
minutes)
Summary (5 minutes)
Welcome, Training Objectives, and Ground Rules
After participants have taken their seats, the trainer introduces
himself or herself and asks participants to introduce themselves
by stating their names, what they do, and one skill they hope to
gain from the training.
The trainer distributes copies of TIP 41 to participants, asks them
to turn to the table of contents (p. iii) of TIP 41, and instructs them
to bring TIP 41 to each training session.
This training is based on the Substance Abuse and Mental Health Services
Administration (SAMHSA)/Center for Substance Abuse Treatment (CSAT)
TIP 41, Substance Abuse Treatment: Group Therapy. TIP 41 is part of a
series of best-practices guidelines developed by SAMHSA/CSAT to assist in
providing practical, up-to-date, evidence-based information on important
topics in substance abuse treatment. The table of contents for the TIP
provides an overview of the training curriculum, which roughly follows the
order of the chapters.
TIP 41 Curriculum

PP 1-2
PP 1-3
PP 1-4
PP 1-5
The group therapy training is divided into seven modules. Module 1 covers
Chapter 1 of TIP 41. After completing all seven modules, you will be able to:
Discuss the use of group therapy in substance abuse treatment.
(Module 1)
Explain five group therapy models and three specialized group therapy
models used in substance abuse treatment. (Modules 1 and 2)
Explain the advantages of group therapy. (Module 1)
Modify group therapy to treat substance abuse. (Module 1)
Explain the stages of change. (Module 2)
Match clients with substance abuse treatment groups. (Module 3)
Assess clients readiness to participate in group therapy. ( Module 3)
Determine clients needs for specialized groups. (Module 3)
Distinguish differences between fixed and revolving membership groups.
(Module 4)
Prepare clients for groups. (Module 4)
(Module 4)
Discuss the importance of making clinical adjustments in group therapy.
(Module 5)
Explain the three stages of treatment. (Module 5)
treatment. (Module 5)
treatment. (Modules 5 and 6)
treatment group therapy. (Module 6)
Identify training opportunities. (Module 7)
Appreciate the value of clinical supervision. (Module 7)
1-2 1-2
1-3
Module 1: Groups and Substance Abuse Treatment

PP 1-6
PP 1-7
45 minutes
The trainer reviews the ground rules, asks participants whether
they would like to add any rules to the list, and writes additional
rules on newsprint.
Begin and end sessions and breaks on time.
Respect others and their opinions.
Allow one person to speak at a time.
Maintain confidentiality.
Participate in each training session.
Have fun.
The goal of Module 1 is to provide an overview of group therapy used in
substance abuse treatment. By the end of the session, you will be able to:
Discuss the use of group therapy in substance abuse treatment.
Define five group therapy models used in substance abuse treatment.
Explain the advantages of group therapy.
Modify group therapy to treat substance abuse.
Presentation: Overview of Group Therapy in Substance Abuse
Treatment
The natural propensity of human beings to congregate makes group
therapy a powerful therapeutic tool for treating substance abuseone that
is as helpful as individual therapy, and sometimes more successful. One
reason for this effcacy is that groups intrinsically have many beneftssuch
as reducing isolation and enabling members to witness the recovery of
othersand these qualities draw clients into a culture of recovery. Another
reason groups work so well is that they are especially suitable for treating
problems that commonly accompany substance abuse, such as depression,
isolation, and shame.
Although many groups can have therapeutic effects, TIP 41 concentrates
only on groups that have trained leaders and that are designed to promote
recovery from substance abuse. Emphasis is placed on interpersonal
process groups, which help clients resolve problems in relating to other
people, problems from which they have attempted to fee by means of
addictive substances. This course does not train individuals to be group
therapy leaders. Rather, it provides substance abuse counselors with
1-4
TIP 41 Curriculum

insights and information that can improve their ability to manage the groups
they currently lead.
The lives of individuals are shaped by their experiences in groups. People
are born into groups; they join groups; they will infuence and be infuenced
by family, social, and cultural groups that constantly shape behavior, self-
image, and both physical and mental health.
PP 1-8
PP 1-9
Group therapy can support members in times of pain and trouble. A groups
therapeutic goals can enrich members with insight and guidance. Group
therapy and addiction treatment are natural allies. The effectiveness of
group therapy in substance abuse treatment can be attributed to several
factors associated with addiction such as depression, anxiety, and denial.
Can you name others?
The trainer encourages participants to name other factors and
writes them on newsprint.
Most groups in substance abuse treatment have trained leaders. In
addition, their goal is to produce healing or recovery from substance abuse.
Five group therapy models are frequently used in substance abuse treatment:
Psychoeducational groups teach about substance abuse.
Skills development groups help members hone skills necessary to break
free of addiction.
Cognitivebehavioral groups encourage members to rearrange patterns
of thinking and action that lead to addiction.
Support groups provide a forum where members can debunk excuses
and support constructive change.
Interpersonal process groups enable members to re-create their past
and rethink problems and solutions that led to their substance abuse.
Treatment counselors routinely use the frst four models and various
combinations of them. The interpersonal process group model is not widely
used in substance abuse treatment because of the extensive training
required to lead such groups and the long duration of the groups; these
groups demand a high degree of commitment from both counselors and
clients.
Module 2 provides more details about each type of group.
Treating adult clients in groups has many advantages but can yield poor
results if applied indiscriminately or administered by an unskilled or
improperly trained leader. There are numerous advantages to using groups
in substance abuse treatment. For example:
1-5
Module 1: Groups and Substance Abuse Treatment

PP 1-10
PP 1-11
PP 1-12
Groups provide positive peer support and pressure for abstinence from
substances of abuse. Group therapy elicits commitment by all the group
members to attend and to recognize that failure to attend, to be on
time, and to treat group time as special disappoints group members and
reduces the groups effectiveness.
Groups reduce the sense of isolation that most people who have
substance use disorders experience. They enable participants to identify
with others who are struggling with the same issues.
Groups enable members who abuse substances to witness the recovery
of others. From this inspiration, people who are addicted gain hope that
they too can maintain abstinence.
Groups help members learn to cope with their substance use problems
by allowing them to see how others deal with similar problems.
Groups can provide useful information to clients who are new to
recovery. Members can learn how to avoid triggers for use, the
importance of abstinence, and how to self-identify as a person
recovering from substance abuse.
Groups provide feedback on the values and abilities of other group
members. This information helps members improve their conception of
self or modify faulty, distorted conceptions.
Groups offer family-like experiences that support and nurture group
members. These experiences may have been lacking in the group
members families of origin.
Groups encourage, coach, support, and reinforce as members undertake
difficult or anxiety-provoking tasks.
Some modifcations are needed to make group therapy applicable to and
effective with clients who abuse substances.
First, group therapy leaders may need specifc training and education
so that they fully understand therapeutic group work and the special
characteristics of clients with substance use disorders. Group therapy is not
individual therapy done in a group, nor is it equivalent to 12-Step program
practices. Group therapy requires that individuals understand and explore
the emotional and interpersonal conficts that can contribute to substance
abuse. The group leader requires specialized knowledge and skill, including
a clear understanding of group process and the stages of development of
group dynamics.
Second, the individual who is chemically dependent usually comes to
treatment with a complex set of defenses and is frequently in denial. The
1-6
TIP 41 Curriculum
group leader should have a clear understanding of each group members
defensive process and character dynamics.
Third, the theoretical underpinnings and practical applications of general
group therapy are not always applicable to individuals who abuse
substances. Clients and even staff members often become confused about
the different types of group therapy modalities. For instance, the course
of treatment may include 12-Step groups, discussion groups, educational
groups, continuing care groups, and support groups. Clients can become
confused about the purpose of group therapy, and staff can underestimate
the impact that group therapy can have. Therefore, the principles of group
therapy need to be tailored to meet the realities of treating clients with
substance use disorders.
5 minutes
Summary
The trainer:
Responds to participants questions or comments.
Encourages participants to review Chapter 1 of TIP 41.
Instructs participants to read Chapter 2 and reminds them to
bring TIP 41 to the next training session.
Reminds participants of the date and time of the next training
session.
2-1

5 minutes
PP 2-1
Module 2: Types of Groups
Used in Substance Abuse
Treatment
Module 2 Overview
The goal of Module 2 is to provide participants with an overview of the
group therapy models used in substance abuse treatment. The information
in Module 2 covers Chapter 2 of Treatment Improvement Protocol (TIP) 41,
Substance Abuse Treatment: Group Therapy. This module takes 1 hour and
45minutestocompleteandisdividedintofvesections:
Module 2 Goal and Objectives (5 minutes)
Presentation: Stages of Change (10 minutes)
Presentation: Five Group Therapy Models in Substance Abuse Treatment
(60 minutes)
Presentation: Three Specialized Group Therapy Models in Substance
Abuse Treatment (25 minutes)
Summary (5 minutes)
Module 2 Goal and Objectives
After participants have taken their seats, the trainer instructs
them to turn to Chapter 2 (p. 9) of TIP 41.
Module 2 covers Chapter 2 of TIP 41.
TIP 41 Curriculum

PP 2-2
10 minutes
PP 2-3
The goal of Module 2 is to provide details about the group therapy models
used in substance abuse treatment. The module also explores specialized
groups and groups that focus on specifc problems. By the end of the
session, you will be able to:
Explain the stages of change.
Describe the five group therapy models used in substance abuse
treatment.
Discuss the three specialized group therapy models used in substance
abuse treatment.
Presentation: Stages of Change
The clients stage of change dictates which group models and methods are
appropriate at a particular time.
Six stages of change have been identifed for individuals with substance
use disorders:
Precontemplation. Individuals are not thinking about changing
substance use behaviors and may not consider their substance use a
problem.
Contemplation. Individuals still use substances, but they begin to think
about cutting back or quitting substance use.
Preparation. Individuals still use substances but intend to stop because
motivation to quit has increased and the consequences of continued use
have become clear. Planning for change begins.
Action. Individuals choose a strategy for discontinuing substance use
and begin to make the changes needed to carry out their plan.
Maintenance. Individuals work to sustain abstinence and avoid relapse.
Recurrence. Many will relapse and return to an earlier stage, but they
may move quickly through the stages of change and may have gained
new insights into problems.
A group comprising members in the action stage who have clearly identifed
themselves as substance dependent will be far different from the one
comprising people who are in the precontemplative stage. Priorities change
with time and experience, too. For example, a group of people in their
second day of abstinence is very different from a group with 2 years in
recovery.
Theoretical orientations also have an impact on the tasks the group is trying
to accomplish, what the group leader observes and responds to in group,
and the types of interventions that the group leader initiates. Before a group
2-2 2-2
2-3
Module 2: Types of Groups Used in Substance Abuse Treatment

model is used in treatment, the group leader and treatment program should
decide on the theoretical framework to be used. Each group model requires
different actions from the group leader. Because most treatment programs
offer a variety of groups for substance abuse treatment, it is important that
these models be consistent with clearly defned theoretical approaches.
60 minutes
PP 2-4
Presentation: Five Group Therapy Models in Substance Abuse
Treatment
For each type of group, the trainer allows participants to share
experiences they have had as members or leaders of that
particular group before moving on to the next group.
Substance abuse treatment programs use a variety of group therapy
models to meet client needs during the multiphase process of recovery.
TIP 41 describes fve group therapy models that are effective for substance
abuse treatment:
Psychoeducational groups
Skills development groups
Cognitivebehavioral/problemsolving groups
Support groups
Interpersonal process groups
Each model has something unique to offer to certain populations, and each
can provide powerful therapeutic experiences for group members. A model,
however, has to be matched with the needs of the particular population
being treated; the goals of a particular group are important determinants of
the model chosen.
Before beginning the discussion on the types of group models,
the trainer asks participants to share their experiences working
with different types of groups.
2-4
TIP 41 Curriculum

PP 2-5
PP 2-6
Variable factors for the fve group models include:
Group or leader focus
Specificity of the group agenda
Heterogeneity and homogeneity of group members
Open ended or determinate duration of treatment
Level of leader activity
Training required for the group leader
Duration of treatment and length of each session
Arrangement of room
The trainer instructs participants to turn to Figure 2-2 in TIP 41
(p. 13) and reviews the figure with participants.
We will now take a look at the purpose, principal characteristics, leadership
skills and styles, and techniques of each of the fve groups.
Psychoeducational groups educate clients about substance abuse
and related behaviors and consequences. This type of group presents
structured, group-specifc content, often using videotapes, audiocassettes,
and lectures. These groups:
Assist individuals in the precontemplative and contemplative stages of
change. Clients learn to reframe the impact of substance use on their
lives, develop an internal need to seek help, and discover avenues for
change.
Help clients in early recovery learn about their disorder. Clients recognize
roadblocks to recovery and begin on a path toward recovery.
Provide family members with an understanding of the behavior of the
person in recovery. Families learn how to support their loved one and
about their own need for change.
Advise clients about other resources and skills that can help in recovery.
Clients can become familiar with other services such as mutual-help
programs and learn skills such as meditation, relaxation, and anger
management.
2-5

PP 2-7
PP 2-8
Psychoeducational groups teach clients that they need to learn to identify,
avoid, and eventually master the specifc internal states and external
circumstances associated with substance use. The coping skills normally
taught in skills development groups often accompany this learning.
Psychoeducational groups:
Work to engage participants in the group discussion and prompt them to
relate what they learn to their own substance abuse.
Are highly structured and often follow a manual or curriculum. The leader
usually takes a very active role in discussions.
Leaders in psychoeducational groups primarily assume the roles of
educator and facilitator. They also have the same core characteristics of
other group leaders: caring, warmth, genuineness, and positive regard for
others. Leaders of psychoeducational groups:
Understand basic group processeshow people interact within a group.
They should know how groups form and develop, how group dynamics
influence an individuals behavior in group, and how a leader affects
group functioning.
Understand interpersonal relationship dynamics, including how people
relate to one another in group settings, how one individual can influence
the behavior of others, and how to handle problem group behavior (such
as being withdrawn).
Have basic teaching skills. Such skills include organizing the content,
planning for participant involvement in the learning process, and
delivering information in a culturally relevant and meaningful way.
Have basic counseling skills (e.g., active listening, clarifying, supporting,
reflecting, attending) and a few advanced counseling skills (e.g.,
confronting, terminating).
2-6
TIP 41 Curriculum

PP 2-9
PP 2-10
PP 2-11
Techniques to conduct psychoeducational groups address how the
information is presented and how to assist clients in incorporating learning
so that it leads to productive behavior, improved thinking, and emotional
change. Techniques:
Foster an environment that supports participation. Lecturing should be
limited, and group discussion should be encouraged.
Encourage participants to take responsibility for their learning. Leaders
should emphasize honest, respectful interactions among all members.
Use a variety of learning methods that require sensory experiences (e.g.,
hearing, sight, touch/movement).
Are mindful of cognitive impairments caused by substance use. People
with addictive disorders are known to have subtle, neuropsychological
impairments in the early stage of abstinence.
Most skills development groups operate from a cognitivebehavioral
orientation. Many skills development groups incorporate psychoeducational
elements into the group process, though skills development may remain the
primary goal of the group. These groups:
Cultivate skills people need to achieve and maintain abstinence.
Assume clients lack needed life skills.
Allow clients to practice skills. Clients see how others use the skills
and receive positive reinforcement from the group when skills are used
effectively.
May be either directly related to substance use or may apply to broader
areas relevant to recovery.
The suitability of a client for a skills development group depends on the
unique needs of the individual and the skills being taught in the group.
Skills development groups:
Have a limited number of sessions and a limited number of participants.
The group must be small enough to allow members to practice the skills
being taught.
Strengthen behavioral and cognitive resources.
Focus on developing an information base on which decisions can be
made and actions taken.
2-7

PP 2-12
PP 2-13
Leaders in skills development groups:
Need basic group therapy knowledge and skills, such as understanding
the ways that groups grow and evolve, knowledge of the patterns that
show how people relate to one another in groups, skills in fostering
interaction among members, and ability to manage conflicts that arise
among members in a group environment.
Know and can demonstrate skills that clients are trying to develop.
Leaders need experience in modeling behavior and helping others learn
discrete elements of behavior.
Are aware of the different ways people approach issues and problems
such as anger or assertiveness.
The specifc techniques used in a skills development group depend on the
skills being taught. The process of learning and incorporating new skills
may be diffcult. Individuals who have been passive and nonassertive may
struggle to learn to stand up for themselves. Many changes that seem
straightforward have powerful effects at deeper levels of psychological
functioning. Techniques:
Vary depending on the skills being taught.
Are sensitive to clients struggles.
Hold positive expectations for change and do not shame individuals who
seem overwhelmed.
Depend on the nature of the group, topic, and approach of the group
leader. Before undertaking leadership of a skills development group, the
leader should have participated in the specific skills development group
to be led.
2-8
TIP 41 Curriculum

PP 2-14
PP 2-15
Cognitivebehavioral groups are a well-established part of the substance
abuse treatment feld and are particularly appropriate in early recovery.
Cognitivebehavioral groups use a wide range of formats informed by a
variety of theoretical frameworks, but the common thread is cognitive
restructuring as the basic methodology of change. Cognitivebehavioral
groups:
Conceptualize dependence as a learned behavior that is subject to
modifications through various interventions, including identification
of conditioned stimuli associated with specific addictive behaviors,
avoidance of such stimuli, development of enhanced contingency
management strategies, and response desensitization.
Work to change learned behavior by changing thinking patterns, beliefs,
and perceptions.
Develop social networks that support continued abstinence so that the
person with dependence becomes aware of behaviors that may lead to
relapse and develops strategies to continue in recovery.
Include a number of different psychological elements, such as thoughts,
beliefs, decisions, opinions, and assumptions. Changing such cognitions
and beliefs may lead to greater opportunities to maintain recovery.
Cognitivebehavioral groups are often used to address ways a client deals
with issues and problems that may be reinforcing substance abuse. These
groups:
Provide a structured environment within which group members can
examine the behaviors, thoughts, and beliefs that lead to maladaptive
behavior.
Sometimes follow a treatment manual that provides specific protocols
for intervention techniques.
Emphasize structure, goal orientation, and a focus on immediate
problems. Problemsolving groups often have a specific protocol that
systematically builds problemsolving skills and resources.
Use educational devices (e.g., visual aids, role preparation, memory
improvement techniques, written summaries, review sessions,
homework, audiotapes) to promote rapid and sustained learning.
Encompass a variety of methodological approaches that focus on
changing cognition (beliefs, judgments, and perceptions) and the
behavior that flows from it. Some approaches focus on behavior, others
on core beliefs, and still others on problemsolving abilities.
2-9

PP 2-16
PP 2-17
Leaders in cognitivebehavioral groups:
Have a solid grounding in the theory of cognitivebehavioral therapy.
Training in cognitivebehavioral therapy is available. Chapter 7 in TIP 41
provides information on training resources.
Are actively engaged in the group and have a consistently directive
orientation.
Allow group members to use the power of the group to develop their
own capabilities. Leaders may be tempted to become the expert in how
to think, how to express that thinking behaviorally, and how to solve
problems. It is important not to yield to such temptation.
Recognize, respect, and work with resistance. Experienced leaders
realize that resistance to change is inevitable and can address it without
confrontation. TIP 35, Enhancing Motivation for Change in Substance
Abuse Treatment, has numerous examples of rolling with resistance.
The specifc techniques used in cognitivebehavioral groups vary depending
on the particular orientation of the leaders. In general, techniques:
Teach group members about self-destructive behavior and thinking that
lead to maladaptive behavior.
Focus on problemsolving and short- and long-term goal setting.
Help clients monitor feelings and behavior, particularly those associated
with substance use.
2-10
TIP 41 Curriculum

PP 2-18
PP 2-19
The widespread use of support groups originated in the self-help tradition of
the substance abuse treatment feld. These groups realize that signifcant
lifestyle change is the long-term goal in treatment and that support groups
can play a major role in such life transitions. The focus of support groups
can range from strong leader-directed, problem-focused groups in early
recovery, which focus on achieving abstinence and managing day-to-day
living, to group-directed, emotionally and interpersonally focused groups in
later stages of recovery. Support groups:
Are useful for apprehensive clients who are looking for a safe
environment.
Bolster members efforts to develop and strengthen their ability to
manage thinking and emotions and to improve interpersonal skills as
they recover from substance abuse.
Address pragmatic concerns, such as maintaining abstinence and
managing day-to-day living.
Improve members self-esteem and self-confidence. The group members
and group leader provide specific kinds of support, such as helping
members avoid isolation and finding something positive to say about
other members contributions.
Support groups always have clearly stated purposes that depend on the
members motivation and stage of recovery. Support groups:
Often are open ended, with a changing population of members. As new
clients move into a particular stage of recovery, they may join a support
group appropriate for that stage until they are ready to move on. Groups
may continue indefinitely, with new members coming and old members
leaving and occasionally returning.
Encourage discussion about members current situations and recent
problems. Discussion usually focuses on staying abstinent.
Provide peer feedback and require members to be accountable to one
another. In cohesive, highly functioning support groups, member-to-
member or leader-to-member confrontation can occur.
2-11

PP 2-20
PP 2-21
Some support groups may be peer generated or led. Leaders are active but
not directive. Leaders:
Need solid grounding in how groups grow and evolve and the ways in
which people interact and change in groups.
Have a theoretical framework in counseling (e.g., cognitivebehavioral
therapy) that informs their approach to support group development,
therapeutic goals for group members, guidance of group members
interactions, and implementation of specific interventions.
Build connections among members and emphasize what members have
in common. It is useful for leaders to have participated in a support
group and to have been supervised in support group work before
undertaking leadership of such a group.
Are usually less directive than they are for other types of groups. The
leaders primary role is to facilitate group discussion and help group
members share their experiences, grapple with their problems, and
overcome difficult challenges.
Provide positive reinforcement, model appropriate interactions,
respect individual and group boundaries, and foster open and honest
communication.
Specifc group techniques are less important in support groups than they
are in other groups, so the leader usually has a less active role in group
direction. The goal is to facilitate the evolution of support within the group.
Techniques:
Vary with group goals and members needs.
Facilitate discussion among members, maintain appropriate group
boundaries, help the group work through obstacles and conflicts, and
provide acceptance of and regard for members.
Ensure that interpersonal struggles among group members do not
hinder the development of the group or any members.
2-12
TIP 41 Curriculum

PP 2-22
PP 2-23
PP 2-24
Interpersonal process groups should be led only by well-trained
professionals. Todays training provides only an overview. The therapeutic
approach of interpersonal process groups focuses on healing by
changing basic intrapsychic (within a person) and interpersonal (between
people) dynamics. For those people who have become dependent on
substances, the interpersonal process group raises and reexamines
fundamental developmental issues. As faulty relationship patterns
are identifed, participants begin to change dysfunctional, destructive
patterns. Participants become increasingly able to form mutually satisfying
relationships with other people. Interpersonal process groups:
Recognize that conflicting forces in the mind, some of which may be
outside ones awareness, determine a persons behavior, whether
healthful or unhealthful.
Address developmental influences, starting in early childhood, and
environmental influences, to which people are particularly vulnerable
because of their genetic and other biological characteristics.
Interpersonal process groups:
Delve into major developmental issues, searching for patterns that
contribute to addiction or interfere with recovery. The group becomes a
microcosm of the way group members relate to people in their lives.
Use psychodynamics, or the way people function psychologically, to
promote change and healing.
Rely on here-and-now interactions of members. Of less importance is
what happens outside the group or what happened in the past.
Leaders must be trained in psychotherapy. Leaders:
Focus on the present, noticing signs of people re-creating their past
in what is going on between and among members of the group. For
example, if a person has a problem with anger, this problem eventually
will be reenacted in the group.
Monitor how group members relate to one another, how each member
is functioning psychological or emotionally, and how the group is
functioning.
2-13

PP 2-25
25 minutes
PP 2-26
PP 2-27
In practice, group leaders may use different models at various times and
may focus on more than one aspect at a time. For example, a group that
focuses on changing the individual will also have an impact on the groups
interpersonal relationships and the group as a whole. Techniques:
Vary depending on the type of process group and the developmental
stage of the group.
Are based on the needs of group members and the needs of the group
as a whole.
Require a high degree of understanding about and insight into group
dynamics and individual behavior.
Presentation: Three Specialized Group Therapy Models in Substance
Abuse Treatment
For each type of group, the trainer allows participants to share
experiences they have had as members or leaders of that
particular group before moving on to the next group.
Three specialized groups, which do not ft into the fve model categories,
function as unique entities in the substance abuse treatment feld:
Relapse prevention groups
Communal and culturally specific groups
Expressive groups (art therapy, dance, psychodrama)
Relapse prevention groups focus on helping a client maintain abstinence or
recover from relapse. Clients need to achieve a period of abstinence before
joining a relapse prevention group. This kind of group is appropriate for
clients who are abstinent but cannot necessarily maintain a drug-free state.
Relapse prevention groups:
Help clients maintain their recovery by providing them with skills to
identify and manage high-risk situations.
Upgrade the clients abilities to manage risky situations and stabilize
clients lifestyles through changes in behavior.
Focus on activities, problemsolving, and skills building.
Increase clients feelings of self-control.
Explore the problems of daily life and recovery.
2-14
TIP 41 Curriculum

PP 2-28
PP 2-29
PP 2-30
Leaders of relapse prevention groups need a set of skills that are similar
to those needed for the skills development group, as well as experience
working in relapse prevention. Group leaders:
Monitor client participation for risk of relapse, signs of stress, and need
for a particular intervention.
Know how to handle relapse and help the group work through such an
event in a nonjudgmental, nonpunitive way.
Understand the range of consequences clients face because of relapse.
Draw on techniques used in cognitivebehavioral, psychoeducational,
skills development, and process-oriented groups.
Communal and culturally specifc groups use a specifc cultures healing
practices and adjust therapy to cultural values. These groups:
Build personal relationships with clients before turning to treatment
tasks.
Can be integrated into a therapeutic group.
Show respect for a culture and its healing practices.
Leaders:
Strive to be culturally competent, avoid stereotypes, and allow clients to
self-identify.
Are aware of cultural attitudes.
SAMHSA has published several books on topics that help counselors
become culturally competent, including TIP 29, Substance Abuse Treatment
for People With Physical and Cognitive Disabilities; TIP 51, Substance
AbuseTreatment:AddressingtheSpecifcNeedsofWomen; and A
Providers Introduction to Substance Abuse Treatment for Lesbian, Gay,
Bisexual, and Transgender Individuals. These books are available from the
SAMHSA Store at http://www.store.samsha.gov. Other resources are listed
in Figure 3-7 (p. 48) of TIP 41.
2-15

PP 2-31
PP 2-32
5 minutes
Expressive groups use therapeutic activities that allow clients to express
feelings and thoughts that may be diffcult to communicate orally.
Expressive groups:
Foster social interaction as group members engage in a creative activity.
Help clients explore their substance abuse, its origins (e.g., trauma), the
effect it has had on their lives, and new options for coping.
Depend on the form of expression clients are asked to use.
Leaders:
Need to be trained in the specific modality being used (e.g., art therapy,
drama therapy).
Can recognize signs related to histories of trauma and can help clients
find the resources they need to work through powerful emotions.
Are sensitive to a clients ability and willingness to participate in the
activity.
Summary
The trainer:
session.
3-1

5 minutes
PP 3-1
Module 3: Criteria for the
Placement of Clients in
Groups
Module 3 Overview
The goal of Module 3 is to provide participants with an overview of how to
match clients with groups depending on clients readiness to change and
their ethnic and cultural experiences. The information in Module 3 covers
Chapter 3 of Treatment Improvement Protocol (TIP) 41, Substance Abuse
Treatment: Group Therapy. This module takes 1 hour to complete and is
dividedintofvesections:
Presentation: Matching Clients With Groups (5 minutes)
Presentation: Assessing Client Readiness for Group (25 minutes)
Presentation: Ethnic and Cultural Experiences in Groups (20 minutes)
Summary (5 minutes)
TIP 41 Curriculum

PP 3-2
PP 3-3
5 minutes
25 minutes
PP 3-4
The goal of Module 3 is to provide an overview of how to match clients with
groups, depending on clients readiness to change and their ethnic and
cultural experiences. By the end of the session, you will be able to:
Match clients with substance abuse treatment groups.
Assess clients readiness to participate in group therapy.
Determine clients needs for specialized groups.
Presentation: Matching Clients With Groups
Matching each individual with the right group is critical for success in group
therapy. Before placing a client in a particular group, the counselor should
consider:
The clients characteristics, needs, preferences, and stage of recovery
The programs resources
The nature of the group or groups available
The clients ethnic and cultural experiences
Placement choices are constantly subject to change. Clients may need to
move to different groups as they progress through treatment, encounter
setbacks, or become more or less committed to recovery. A client can
move from a psychoeducational group to a relapse prevention group to an
interpersonal process group. The client can also participate in more than
one group at the same time.
Presentation: Assessing Client Readiness for Group
Placement begins with a thorough assessment of the clients ability to
participate in the group and the clients needs and desires for treatment.
This assessment begins when the client enters treatment and continues
during the initial interview and through as long as the frst 4 to 6 weeks of
group participation.
The assessment should inquire about all drugs used and look for cross-
addictions. The client should be asked about his or her social network and
experiences with and roles in groups in the past.
Clinical observation and judgment, information from collateral resources,
and fndings of assessment instruments should contribute to the decision
on a clients readiness and appropriateness for group therapy. Either the
group leader or another trained staff person should meet with the client
before assignment to a group to evaluate how the client reacts to the group
leader and to assess interpersonal relationship experiences. The client can
also be observed in a waiting room with other clients to gain insight into
how he or she relates to others.
3-2 3-2
3-3
Module 3: Criteria for the Placement of Clients in Groups

The counselor pays careful attention to a clients relationships at the
current stage of recovery because these relationships can reveal the
clients ability to participate in groups. Clients need to be able to engage
with others.
Not all clients are equally suited for all kinds of groups, nor is any group
approach necessary or suitable for all clients with a history of substance
abuse. For instance, a person who relapses frequently probably would be
inappropriate in a support group of individuals who are in the process of
resolving practical life problems. A person who is in the throes of acute
withdrawal from crack cocaine does not belong in a group with people who
have been abstinent for 3 months. Groups usually can be demographically
heterogeneous (e.g., men and women, young and old clients, people of
different races and ethnicities), but clients should be placed in groups with
people with similar needs.
PP 3-5
Some clients may be inappropriate for group therapy:
Clients who refuse to participate. No one should be forced to participate
in group therapy.
Clients who cannot honor group agreements. Sometimes, clients can
have disqualifying pathologies such as personality disorders or paranoia.
In other instances, clients cannot attend groups for logistical reasons
such as a conflicting work schedule.
Clients who are unsuitable for group therapy. Such people might be
prone to dropping out or acting in ways contrary to the interests of the
group.
Clients in the throes of a life crisis. Such clients require more
concentrated attention than groups can provide.
Clients who cannot control impulses. Such clients may be suitable for
homogeneous groups.
Clients whose defenses would clash with the dynamics of the group.
These people include those who cannot tolerate strong emotions or get
along with others.
Clients who experience severe internal discomfort in groups.
A formal selection process is essential to match clients with the groups best
suited to meet their needs. Client evaluators should review completed forms
and meet with each candidate for group placement. The evaluator should
listen carefully to determine the clients hopes, fears, and preferences.
After specifying the appropriate treatment level, a counselor meets with
the client to identify options consistent with this level of care. More specifc
screens are needed to determine whether the client is appropriate for
treatment in a group modality.
3-4
TIP 41 Curriculum

PP 3-6
20 minutes
PP 3-7
TIP 41 identifes several primary placement considerations:
Women. Studies have shown that women do better in women-only
groups than in mixed-gender groups. Women are more likely than men to
have experienced traumatic events. Women are less willing to disclose
their victimization in mixed-gender groups.
Adolescents. Local, State, and Federal laws related to confidentiality;
infectious disease control; parental permission and notification; child
abuse, neglect, and endangerment; and statutory rape are important
factors when substance abuse treatment services are delivered to
minors. Other complications include school scheduling and the need to
include family in the treatment process.
Level of interpersonal functioning, including impulse control. Two
questions to consider when determining a clients level of functioning in
a group setting include:
Does the client pose a threat to others?
Is the client prepared to engage in the give and take of groups dynamics?
Motivation to abstain. Clients with low levels of motivation should be
placed in psychoeducational groups, which can help them make the
transition to the recovery-ready stage.
Stage of recovery. Different types of groups are appropriate for clients
at the different stages of recovery. Figure 3-2 in TIP 41 (p. 43) indicates
client placement in specific groups based on the clients stage of
recovery. Figure 3-3 in TIP 41 (p. 44) indicates client placement in
groups based on the readiness for change model discussed in Module 2.
Expectation of success. Clients are expected to succeed in the groups. A
poor match can be identified early through group monitoring. The group
cannot succeed unless each member of the group gets something out of
the experience.
Presentation: Ethnic and Cultural Experiences in Groups
Ethnic and cultural diversity issues take on added importance in a
therapeutic group composed of many different kinds of people. As
group therapy proceeds, feelings of belonging to an ethnic group can be
intensifed more than in individual therapy because in the group process
the individual may engage many peers who are different, not just the
counselor who is different.
Diversity in TIP 41 means differences that distinguish an individual from
others and that affect how an individual identifes himself or herself and
how others identify him or her. It includes consideration of age, gender,
cultural background, sexual orientation, ability level, social class, education
level, spiritual background, parental status, and justice system involvement.
3-5
PP 3-8
A culturally homogeneous group tends to adopt roles and values from
its culture of origin. However, group leaders should be aware that these
roles may confict with treatment requirements. If a group leader believes
that cultural traditions might be a factor in a clients participation or in
misunderstandings among group members, the leader should check the
accuracy of that perception with the client involved. However, individuals
cannot always perceive or articulate their cultural assumptions.
Group leaders should anticipate a particular groups characteristics without
automatically assigning them to all individuals in that group. For instance,
it is a mistake for a program to assign all immigrants to a single group and
assume they would be comfortable together.
Leaders should be open and ready to learn all they can about their clients
cultures. Ethnicity and culture have a profound effect on many aspects of
treatment.
Group leaders should be conscious of how their own backgrounds affect
their ability to work with particular populations. For example, a group
therapy leader who has survived domestic violence may have diffculties
working with spouse abusers.
The greater the mix of ethnicities in a group, the more likely that biases will
emerge and require mediation. A client should not be asked to give up any
cultural beliefs, feelings, or attitudes. The client should be encouraged to
share these beliefs even though they may upset other members. Although
group leaders may be uncomfortable when a member talks about racism
and bigotry, such expressions may be an important part of a persons
recovery process.
3-6
TIP 41 Curriculum

PP 3-9
Before placing a client in a particular group, the counselor needs to
understand the infuence of culture, family structure, language, identity
processes, health beliefs and attitudes, political issues, and stigma
associated with minority status for each client who is a potential candidate
for the group. The counselor needs to:
Address the substance use problem in a manner that is congruent with
the clients culture. For instance, some cultures use substances as part
of rituals. This entwinement of substance use and culture does not
mean that the counselor cannot discuss the issue of this substance use
with a client. Some clients will reduce or eliminate the use of substances
once they examine their beliefs and experiences.
Appreciate that particular cultures use substances, usually in
moderation, at specified social occasions. A culturally sensitive
discussion of this issue with clients may result in individual decisions to
abstain on these occasions, despite cultural pressure to use.
Assess the behaviors and attitudes of current group members to
determine whether a new client would match the group. Because
group members are less restricted to their usual social circles and
customary ethnic and cultural boundaries, the group is potentially a
social microcosm within which members may safely try out new ways
of relating. Nevertheless, potential problems between a candidate
and existing group members should be identified and counteracted to
prevent dropout and promote engagement cohesion among members.
Understand personal biases and prejudices about specific cultural
groups. A group leader should be conscious of personal biases to be
aware of countertransference issues, to serve as a role model for the
group, and to create group norms that permit discussion of prejudices
and other sensitive topics.
3-7

PP 3-10
PP 3-11
Four major processes that occur within multiethnic groups have been
identifed:
Symbolism and nonverbal communication. In some cultures, direct
expression of thoughts and feelings is considered unseemly; symbolic
gestures or nonverbal signals communicate indirectly and acceptably.
The group leader should intervene if nonverbal communications are
misinterpreted.
Cultural transference of traits from one person of a certain culture
to another person of that culture. If a member has had experiences
(usually negative) with people of the same ethnicity as the group leader,
the group member may transfer to the leader feelings and reactions
developed with others of the leaders ethnicity. To dispel such feelings
and reactions, the group leader should detect these misconceptions and
reveal them for what they are.
Cultural countertransference, the group leaders (often subconscious)
emotional reaction to a client. Countertransference of culture occurs
when a leaders response to a current group member is based on
experience with a former group member of the same ethnicity as the
new client. Group leaders should exercise restraint in these situations.
Ethnic prejudice. In multiethnic groups, it is vital to develop an
environment in which it is safe to talk about race. Not to do so results in
scapegoating or division along racial lines.
In practice, people connect and diverge in ways that cannot be predicted
solely on the basis of ethnic or cultural identity. Two people from different
ethnic backgrounds may share many other common experiences that
provide a basis for identifcation and mutual support. Leaders are
responsible for considering carefully the positions of people who are
different in some way, especially when planning fxed-membership groups.
To promote group cohesion and welcome new members, the group leader
should:
Inform members in advance that people from a variety of racial and
ethnic backgrounds will be in the group.
Discuss the differences at appropriate times in a sensitive way to provide
an atmosphere of openness and tolerance.
Set the tone for an open discussion of differences in beliefs and feelings.
3-8
TIP 41 Curriculum

PP 3-12
PP 3-13
5 minutes
Help clients adapt to and cope with prejudice in effective ways, while
maintaining their self-esteem.
Integrate new clients into the group slowly, letting them set their own
pace.
When new members start to make comments about others or to accept
feedback, encourage more participation.
Although arguments for matching the ethnicity of a group leader with that of
the group members being treated may have some merit, the reality is that
such a course seldom is feasible. Healthcare providers from culturally and
linguistically diverse groups are underrepresented in the current service
delivery system, so the group leader will likely be from the mainstream
culture. Although it might be ideal to match all participants by ethnicity in
a therapeutic group, the most important determinants for success are the
values and attitudes shared by the group leader and group members.
Groups may include people who have varying:
Expectations of leaders (Some cultures might consider leaders
problemsolvers, whereas in other cultures leaders might be considered
equals until proven otherwise.)
Experience in decisionmaking and conflict resolution
Understanding of gender roles, families, and community
Values
Summary
The trainer:
session.
4-1

5 minutes
PP 4-1
Module 4: Group
Development and Phase
Specific Tasks
Module 4 Overview
The goal of Module 4 is to provide participants with an overview of the uses
offxedandrevolvinggroupsandanoverviewofthetasksforthethree
phases of group development. The information in Module 4 covers Chapter
4 of Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment:
Group Therapy. This module takes 1 hour to complete and is divided into
fvesections:
Presentation: Fixed and Revolving Membership Groups (10 minutes)
Presentation: Preparing for Client Participation in Groups (25 minutes)
Presentation: Phase-Specific Group Tasks (15 minutes)
Summary (5 minutes)
TIP 41 Curriculum

PP 4-2
10 minutes
PP 4-3
PP 4-4
The goal of Module 4 is to provide an overview of fxed and revolving
membership groups and an overview of the tasks for the three phases of
group development. By the end of the session, you will be able to:
Distinguish the differences between fixed and revolving membership groups.
Prepare clients for groups.
Presentation: Fixed and Revolving Membership Groups
Members of fxed membership groups generally stay together for a long
time. Members in revolving membership groups remain in the group only
until they accomplish their goals. Each is used for different purposes, and
each requires different leadership.
Fixed membership groups are small (not more than 15 members) and
membership is stable. The group leader usually screens prospective members,
who are prepared for participation. Fixed membership groups can be:
Time limited. The same group of people attends a specified number
of sessions, generally starting and finishing together. Learning builds
on what has taken place in prior meetings. Members need to be in the
group from its start. New members are admitted only in the earliest
stages of group development. Time-limited groups are used for skill-
building, psychoeducational, and relapse prevention groups.
Ongoing. New members fill vacancies in a group that continues over a
long period. The size of the group is set. The leader generally is less active
than is the leader of a time-limited group because interaction among
group members is more important than leader-to-member interactions.
Leaders need substantial training in group dynamics. Ongoing groups are
used for interpersonal process and some psychoeducational groups.
Fixed groups are rare in substance abuse treatment because they demand
a long-term commitment of resources.
New members enter a revolving membership group when they become
ready for the services it provides. Revolving groups must adjust to frequent
unpredictable changes. Revolving groups are also:
Time limited. Each member attends a specified number of sessions,
generally starting and finishing at his or her own pace.
Ongoing. The member remains until he or she has accomplished his or
her specified goals.
These groups are frequently found in inpatient treatment programs.
Revolving member groups tend to be larger than fxed membership groups.
However, if they are larger than 20 members, group interactions break down.
4-2 4-2
4-3
Module4:GroupDevelopmentandPhaseSpecifcTasks

25 minutes
PP 4-5
PP 4-6
Revolving membership groups are structured and require active leadership.
Participation and learning are not highly dependent on previous sessions.
Members who have been in the group for several meetings often help orient
new members.
Figure 4-1 in TIP 41 (p. 62) provides a comparison of the characteristics of
fxed and revolving membership groups.
Presentation: Preparing for Client Participation in Groups
The process of preparing the client for participation in group therapy begins
as early as the initial contact between the client and the program. Group
leaders should conduct an initial individual session with the candidate for
group to form a therapeutic alliance, to reach consensus on what is to be
accomplished in therapy, to educate the client about group therapy, to allay
anxiety related to joining a group, and to explain the group agreement.
The longer the expected duration of the group, the longer the preparation
phase. During this time, the group leader learns how the client handles
interpersonal functions, how the clients family functions, and how the
clients culture perceives the substance use problem.
Preparation meetings ensure that clients understand expectations and will
be able to meet them, and they help clients become familiar with the group
therapy process. Client preparation should:
Explain how group interactions compare with those in self-help groups.
Clients should be informed that member-to-member cross-talk, which is
discouraged in 12-Step groups, is essential in interactive group therapy.
Emphasize that treatment is a long-term process. Clients should know that
each persons attendance at each session is vital during this process.
Let new members know they may be tempted to leave the group at times.
Clients gain a great deal from persistent commitment to the process
and should resist temptations to leave the group. Clients should be
encouraged to discuss thoughts about leaving the group as they arise.
Give prospective members an opportunity to express anxiety about group
work. Misperceptions should be countered to keep them from interfering
with group participation.
Recognize and address clients therapeutic hopes. Leaders can use this
information to place clients in groups most likely to fulfill their aspirations.
Leaders should be sensitive to people who are different from the majority of
other participants in some way. Clients should always be allowed to be the
experts on their own situations.
Leaders are responsible for raising the level of the group members sensitivity
and empathy. They must sometimes prepare group members for a situation
in which others have symptoms that could offend or repel them.
4-4
TIP 41 Curriculum

PP 4-7
PP 4-8
PP 4-9
Retention rates are affected positively by client preparation, maximum
client involvement during the early stage of treatment, the use of feedback,
prompts to encourage attendance, and the provision of wraparound
services to make it possible to attend sessions regularly. Consideration
needs to be given to the timing and length of groups. To achieve maximum
involvement in group therapy, motivational techniques may be used to
engage clients.
Techniques that increase retention include the following:
Role induction uses interviews, lectures, and films to educate clients
about the reasons for therapy, setting realistic goals for therapy,
expected client behaviors, and so on.
Vicarious pretraining uses interviews, lectures, films, and other settings
to demonstrate what takes place during therapy so that the client can
experience the process vicariously.
Experiential pretraining uses group exercises to teach client behaviors
such as self-disclosure and examination of emotions.
Motivational interviewing uses specific listening and questioning
strategies to help clients overcome doubts about making changes.
Prompts remind clients that upcoming group sessions are important in
engaging members during the first 3 months of treatment.
A group agreement establishes the expectations that group members
have for one another, the leader, and the group. Many leaders require that
group members entering a long-term fxed membership group commit to
remaining in the group for a set period. The group agreement is intended to
inspire clients to accept the basic rules and premises of the group and to
increase their determination and ability to succeed.
A group agreement should include at least eight elements.
Communicating grounds for exclusion. The terms under which clients
will be excluded from the group should be made explicit in the group
agreement, so exclusion does not come as a surprise. Some stipulations
in the group agreement might have to incorporate legal requirements
because court-mandated treatment groups may have attendance criteria
set by the State.
Confidentiality. Group members should be asked not to discuss anything
outside the group that could reveal the identity of other members.
The leader should emphasize that confidentiality is critical and should
encourage members to honor their pledge of confidentiality. The
principle that whats said in the group stays in the group is a way of
delineating group boundaries and increasing trust.
4-5

Physical contact. Touch in a group is never neutral. People have different
personal histories and cultural backgrounds that lead to different
interpretations of what touch means. Consequently, the leader should
evaluate carefully any circumstance in which physical contact occurs,
even when it is intended to be positive. In most groups, touch as part of
a group ritual is not recommended. Group agreements always should
include a clause prohibiting violence.
Use of mood-altering substances. Some programs, such as those
connected to criminal justice systems, have policies that require
expulsion of members who are using drugs of abuse. Counselors
are required to report these violations. Part of client preparation
and orientation is to explain all legally mandated provisions and
consequences for failure to comply with treatment guidelines. Members
also should pledge to discuss a return to use promptly after it occurs,
providing the group rules permit and encourage such disclosures.
Contact outside the group. Clients who have bonded in group are likely
to communicate outside the group and may encounter one another at
self-help meetings. Group members need to be told and reminded that
new intimate relationships are hazardous to early recovery. Any contacts
outside the group should be discussed openly in the group.
Participation in the group. The agreement should specify what group
members are expected to divulge. Group members should be willing
to discuss the issues that brought them to group. They should not be
required to share personal information until they feel safe enough to
do so.
Financial responsibility. The agreement may specify a commitment
to discuss any problems that occur in making payments and the
circumstance under which a group member is held responsible for
payment. For example, members should know ahead of time that
they will be financially responsible for missed sessions if that is the
agency policy.
Termination. Group agreements should specify how group members
handle termination. Because group members often are tempted to leave
the group prematurely, the agreement should emphasize the need to
involve the group in termination decisions. However, members make
their own choices about discontinuing treatment.
4-6
TIP 41 Curriculum

15 minutes
PP 4-10
Presentation: Phase-Specific Group Tasks
Every group has a beginning, middle, and end. These phases occur at
different times for different types of groups.
During the beginning phase, the purpose of the group is articulated,
working conditions of the group are established, members are introduced,
a positive tone is set, and group work begins. This phase may last from
10 minutes to a number of months. In a revolving group, this orientation
will happen each time a new member joins the group. Five activities are
conducted in the beginning phase:
Introductions. Even in short-term revolving membership groups, it is
important for the leader to connect with each member. All members
should give their names and say something about themselves. The
leader can build bridges between the old and new members by
encouraging old members to help new members join.
Group agreement review. The group members should review and discuss
the group agreement. The leader should ask members whether they
have concerns that might require additional provisions to make the
group safe. The agreement should be reviewed periodically during the
course of the group.
Providing a safe, cohesive environment. All members should feel that they
have a part to play in the group and have something in common. This
cohesion affects the productivity of work throughout the therapeutic process.
Establishment of norms. The group leader is responsible for ensuring
that healthful norms are established and that counterproductive norms
are precluded, ignored, or extinguished. The leader shapes norms
through responses to events in the group and by modeling the behavior
expected of others.
Initiation of group work. The leader facilitates group work by providing
information or encouraging honest exchanges among members. Most
leaders strive to keep the group focused on the here and now.
PP 4-11
The group in the middle phase encounters and accomplishes most of the
therapy work. During this phase, the leader balances content, which is the
information and feelings overtly expressed in the group, and process, which
is how members interact in the group. The therapy is both the content and
the process. Both contribute to the connections between and among group
members.
The group is the forum where clients interact with others. Through give and
take, clients receive feedback that helps them rethink their behaviors and
move toward productive changes. Leaders allocate time to address issues
that arise, pay attention to relations among group members, and model a
healthful interactional style that combines honesty with compassion.
4-7

PP 4-12
5 minutes
Termination is an important opportunity for members to honor the work
they have done, to grieve the loss of associations and friendships, and to
look forward to a positive future. Group members learn and practice saying
good-bye, understanding that it is necessary to make room in their lives
for the next hello.
This phase begins when the group reaches its agreed-on termination point
or a member determines it is time to leave the group. Termination is a time
for:
Putting closure on the experience
Examining the impact of the group on each person
Acknowledging the feelings triggered by departure
Giving and receiving feedback about the group experience and each
members role in it
Completing any unfinished business
Exploring ways to continue learning about topics discussed in the group
Completing a group successfully can be an important event for group
members when they see the conclusion of a diffcult but successful
endeavor. The longer members have been with the group, the longer they
may need to spend on termination.
Summary
The trainer:
session.
5-1

5 minutes
PP 5-1
Module 5: Stages
of Treatment
Module 5 Overview
The goal of Module 5 is to provide participants with an overview of
adjustments that can be made in the early, middle, and late stages of
treatment. The information in Module 5 covers Chapter 5 of Treatment
Improvement Protocol (TIP) 41, Substance Abuse Treatment: Group
Therapy. This module takes 1 hour to complete and is divided into four
sections:
Presentation: Adjustments To Make Treatment Appropriate (5 minutes)
Presentation: The Stages of Treatment (45 minutes)
Summary (5 minutes)
TIP 41 Curriculum

PP 5-2
PP 5-3
5 minutes
The goal of Module 5 is to provide an overview of adjustments that can
made in the early, middle, and late stages of treatment. By the end of the
session, you will be able to:
Discuss the importance of making clinical adjustments in the group
therapy.
Explain the three stages of treatment.
treatment.
treatment.
Presentation: Adjustments To Make Treatment Appropriate
Treatment has three stages:
In the early stage of treatment, clients can be emotionally fragile,
ambivalent about relinquishing chemicals, and resistant to treatment.
Treatment strategies focus on immediate concerns: achieving
abstinence, preventing relapse, and managing cravings. In this stage
leaders emphasize hope, group cohesion, and universality.
In the middle stage of treatment, clients need the groups assistance in
recognizing that their substance abuse causes many of their problems
and blocks them from getting the things they want. As clients sever their
ties with substances, they need help managing their loss and finding
healthful substitutes.
In the last stage of treatment, clients spend less time on their substance
abuse issues and turn toward identifying the treatment gains to be
maintained and risks that remain. Clients focus on the issues of living,
resolving guilt, reducing shame, and adopting a more introspective view
of themselves.
Therapeutic strategies change as clients move through the different stages.
Interventions that worked well early in treatment may be ineffective and
even harmful later in treatment. Stages of recovery and stages of treatment
will not correspond perfectly for all people. Clients move in and out of
recovery stages in a nonlinear process.
Adjustments in treatment are needed because progress through the stages
is not time bound. There is no way to calculate how long an individual will
require to resolve the issues that arise in any stage of recovery.
Therapeutic interventions may not account for all of the changes in a
particular individual. Generalizations about stages of treatment may not
apply to every client in every group.
5-2 5-2
5-3
Module 5: Stages of Treatment

45 minutes
PP 5-4
PP 5-5
Presentation: The Stages of Treatment
Typically, people who abuse substances do not enter treatment on their
own. Some enter treatment because of health problems; others begin
treatment because they are referred or mandated by the criminal justice
system, employers, or family members. Group members commonly are in
extreme emotional turmoil, grappling with intense emotions such as guilt,
shame, depression, and anger about entering treatment. Consequently, the
group leader faces the challenge of treating resistant clients. Emphasis is
placed on acculturating clients into a new culture, the culture of recovery.
Eleven therapeutic factors contribute to healing as group therapy unfolds:
1. Instilling hope. Some group members exemplify progress toward
recovery and support others in their efforts.
2. Universality. Groups enable clients to see that they are not alone and
that others have similar problems.
3. Imparting information. Leaders shed light on the nature of addiction
via direct instruction.
4. Altruism. Group members gain greater self-esteem by helping one
another.
5. Corrective recapitulation of the primary family group. Groups provide
a family-like context in which longstanding unresolved conflicts can
be revisited and constructively resolved.
6. Developing socializing techniques. Groups give feedback; others
impressions reveal how a clients ineffective social habits might
undermine relationships.
7. Imitative behavior. Groups permit clients to try out behaviors of others.
8. Interpersonal learning. Groups correct the distorted perceptions of
others.
9. Group cohesiveness. Groups provide a safe environment within
which people feel free to be honest and open with one another.
10. Catharsis. Groups liberate clients as they learn how to express
feelings and reveal what is bothering them.
11. Existential factors. Groups aid clients in coming to terms with hard
truths such as life can be unfair; life can be painful, and death is
inevitable; no matter how close one is to others, life is faced alone; it
is important to live honestly and not get caught up in trivial matters;
each of us is responsible for the ways in which we live.
In different stages of treatment, some of these therapeutic factors receive
more attention than others.
5-4
TIP 41 Curriculum

PP 5-6
PP 5-7
PP 5-8
Clients usually come to the frst session of group in an anxious,
apprehensive state of mind, which is intensifed by the knowledge that they
will be revealing personal information and secrets about themselves. The
leader begins by stressing that clients have some things in common.
During early treatment, a leader actively engages clients in the treatment
process. Clients early on usually respond to group leaders who are
spontaneous and engaging. The leader should not be overly charismatic
but should be a strong enough presence to meet clients dependence
needs during the early stage of treatment. During early treatment, effective
leaders focus on immediate primary concerns:
Achieving abstinence
Preventing relapse
Learning ways to manage cravings
Cognitive capacity usually begins to return to normal in the middle stage
of treatment. A person addicted to cocaine, for example, is dramatically
different after 4 months of nonuse. Still, the mind can play tricks.
Clients may remember distinctly the comfort of their past substance
use yet forget how bad the rest of their lives were and the seriousness
of the consequences that loomed before they came into treatment. The
temptation to relapse remains a concern.
In the middle stage of treatment, as the client experiences some stability,
the therapeutic factors of self-knowledge and altruism can be emphasized.
Universality, identifcation, cohesion, and hope remain important.
As the recovering clients mental, physical, and emotional capacities grow
stronger, emotions of anger, sadness, terror, and grief may be expressed
more appropriately.
Clients need to use the group as a means of exploring their emotional and
interpersonal world. They learn to differentiate, identify, name, tolerate, and
communicate feelings.
Cognitivebehavioral interventions can provide clients with specifc tools
to help modulate feelings and to become more confdent in expressing and
exploring them. Interpersonal process groups are particularly helpful in the
middle stage of treatment because the authentic relationships within the
group enable clients to experience and integrate a wide range of emotions
in a safe environment.
5-5
Module 5: Stages of Treatment

PP 5-9
PP 5-10
When pointing out contradictions in clients statements and interpretations
of reality, leaders should ensure that confrontations are well timed, specifc,
and indisputably true. Another way of understanding confrontation is to see
it as an outcome rather than as a style. From this point of view, the leader
helps group members see how their continued use of drugs or alcohol
interferes with what they want to get out of life. In the middle stage, the
leader helps clients join a culture of recovery in which they grow and learn.
The leaders task is to engage members actively in the treatment and
recovery process. To prevent relapse, clients need to learn to monitor their
thoughts and feelings, paying attention to internal cues.
The leader can support the process of change by drawing attention to
new and positive developments and affrming the possibility of increased
connections and new sources of satisfaction. The leader helps individuals
assess the degree of structure and connection they need as recovery
progresses.
In the late (also referred to as ongoing or maintenance) stage of treatment,
clients work to sustain the achievements of previous stages, but also learn
to anticipate and avoid tempting situations and triggers that set off renewed
substance use. To deter relapse, the lifestyle that once promoted drinking
and drug use are sought out and severed.
Many clients, even those who have reached the late stage of treatment, do
return to substance use and an earlier stage of change. Clients who return
to substance abuse do so with new information. With it, they may be able to
discover and acknowledge that some of the goals they set are unrealistic,
certain strategies are ineffective, and environments deemed safe are not at
all conducive to successful recovery. With greater insight into the dynamics
of their substance abuse, clients are better equipped to make another
attempt at recovery and ultimately to succeed.
As the substance use problem fades into the background, signifcant
underlying issues often emerge, such as poor self-image, relationship
problems, the experience of shame, or past trauma.
When the internalized pain of the past is resolved, the client will begin to
understand and experience healthful mutuality, resolving conficts without
the maladaptive infuence of alcohol or drugs. If the underlying conficts are
left unresolved, however, clients are at increased risk of other compulsive
behavior, such as excessive exercise, overeating, overspending, gambling,
and excessive sexual activity, among others.
5-6
TIP 41 Curriculum

PP 5-11
PP 5-12
5 minutes
In the early and middle stages of treatment, clients necessarily are so
focused on maintaining abstinence that they have little or no capacity to
notice or solve other kinds of problems. In late-stage treatment, however, the
focus of group interaction broadens. It attends less to the symptoms of drug
and alcohol abuse and more to the psychology of relational interactions.
Clients begin to learn to engage in life. As they begin to manage their emotional
states and cognitive processes more effectively, they can face situations that
involve confict or emotion. A process-oriented group may become appropriate
for some clients who can confront painful realities, such as being abused as a
child or being an abusive parent. Other clients may need groups to help them
build healthier relationships, communicate more effectively, or become better
parents. Some may want to develop job skills. As group members become
increasingly stable, they can begin to probe deeper into the relational past. The
group can be used to settle diffcult and painful old business.
The leader plays a very different role in the late stage of treatment, which
refocuses on helping group members expose and eliminate personal defcits
that endanger recovery. Gradually, the leader shifts toward interventions that
call on clients to take a clear-headed look at their inner world and system of
defenses, which have prevented them from accurately perceiving their self-
defeating behavioral patterns. To become adequately resistant to substance
abuse, clients should learn to cope with confict without using substances to
escape reality, self-soothe, or regulate emotions.
As in the early and middle stages, the leader helps group members sustain
abstinence and makes sure the group provides enough support and gratifcation
to prevent acting out and premature termination. Late-stage interventions
permit more intense exchanges. Thus, in late treatment, clients are no longer
cautioned against feeling too much. The leader no longer urges them to apply
slogans like Turn it over and One day at a time. Clients should manage the
conficts that dominate their lives, predispose them to maladaptive behaviors,
and endanger their hard-won abstinence. The leader allows clients to experience
enough anxiety and frustration to identify destructive and maladaptive patterns.
Summary
The trainer:
session.
6-1

5 minutes
PP 6-1
Module 6: Group Leadership,
Concepts,
and Techniques
Module 6 Overview
The goal of Module 6 is to provide participants with an overview of
desirable leader traits and behaviors and an overview of the concepts and
techniques vital to process groups. The information in Module 6 covers
Chapter 6 of Treatment Improvement Protocol (TIP) 41, Substance Abuse
Treatment: Group Therapy. This module takes 1 hour to complete and is
divided into four sections:
Presentation: The Group Leader (20 minutes)
Presentation: Concepts and Techniques (30 minutes)
Summary (5 minutes)
TIP 41 Curriculum

PP 6-2
20 minutes
PP 6-3
PP 6-4
The goal of Module 6 is to provide an overview of desirable leader traits and
behaviors and an overview of the concepts and techniques vital to process
groups. By the end of the session, you will be able to:
Discuss the characteristics of group leaders.
treatment group therapy.
Presentation: The Group Leader
When working with people who have substance use disorders, an effective
leader uses the same skills, qualities, styles, and approaches needed
in any kind of therapeutic group. The particular personal and cultural
characteristics of the clients in the group also infuence the leaders
tailoring of therapeutic strategies to ft the particular needs of the group.
Clients typically respond to a warm, empathic, and life-affrming manner.
Group leaders should communicate and share the joy of being alive. This
life-affrming attitude carries the unspoken message that a full and vibrant
life is possible without alcohol or drugs. The leader is responsible for
making a series of choices as the group progresses. The leader chooses:
How much leadership to exercise
How to structure the group
When to intervene
How to effect a successful intervention
How to manage the groups collective anxiety
The means of resolving numerous other issues
It is essential for the leader to be aware of the choices made and to
remember that all choices concerning his or her leadership and the groups
structure have consequences.
TIP 41 identifes nine personal qualities of leaders:
Constancy. An environment with small, infrequent changes is helpful
to clients living in the emotionally turbulent world of recovery. Group
leaders can emphasize the reality of constancy and security through
their behavior. For example, group leaders should always sit in the same
place in group, maintain consistent start and end times and ground rules
for speaking, and even dress in a consistent manner.
Active listening. Excellent listening skills are the keystone of any effective
therapy. Therapeutic interventions require the leader to perceive
and to understand both verbal and nonverbal cues to meaning and
metaphorical levels of meaning.
6-2 6-2
6-3
Module 6: Group Leadership, Concepts, and Techniques

Firm identity. A firm sense of their own identities, together with clear
reflection on experiences in group, enables leaders to understand and
manage their own emotional lives. For example, leaders who are aware of
their own capacities and tendencies can recognize their own defenses as
they come into play in the group. Group work can be intensely emotional.
Leaders who are not in control of their own reactions can do significant
harmparticularly if they cannot admit to a mistake or apologize for it.
Confidence. Effective leaders operate between the certain and the
uncertain. In that zone, they cannot rely on formulas or supply easy
answers to clients complex problems. Instead, leaders have to model the
consistency that comes from self-knowledge and clarity of intent, while
remaining attentive to each clients experience and the unpredictable
unfolding of each sessions work. This secure grounding enables the
leader to model stability for the group.
Spontaneity. Good leaders are creative and flexible.
Integrity. Leaders should be familiar with their institutions policies and
with pertinent laws and regulations. Leaders also need to be anchored by
clear internalized standards of conduct and able to maintain the ethical
parameters of their profession.
Trust. Leaders should be able to trust others.
Humor. Leaders need to be able to use humor appropriately, which means
that it is used only in support of therapeutic goals and never is used to
disguise hostility or wound anyone.
Empathy. One of the cornerstones of successful group therapy for
substance abuse, empathy is the ability to identify someone elses
feelings while remaining aware that the feelings of others are distinct
from ones own. For the counselor, the ability to project empathy is an
essential skill. An empathic leader:
Communicates respect for and acceptance of clients and their feelings.
Encourages in a nonjudgmental, collaborative relationship.
Is supportive and knowledgeable.
Sincerely compliments rather than denigrates or diminishes another
person.
Tells less and listens more.
Gently persuades but understands that the decision to change is the
clients.
Provides support throughout the recovery process.
One of the feelings that the leader needs to empathize with is shame,
which is common among people with substance use histories. Shame is so
powerful that it should be addressed whenever it becomes an issue.
Group therapy with clients who have histories of substance abuse requires
active, responsive leaders who keep the group lively and on task and ensure
that members are engaged continuously and meaningfully with one another.
6-4
TIP 41 Curriculum

PP 6-5
Leaders vary therapeutic styles to meet the needs of clients. During the
early and middle stages of treatment, the leader is active, becoming
less so in the late stage. To determine the type of leadership required
to support a client in treatment, the leader should consider the clients
capacity to manage affect, level of functions, social supports, and
stability. These considerations are essential to determine the type of
group best suited to meet the clients needs.
Leaders model behavior. It is more useful for the leader to model group-
appropriate behaviors than to assume the role of mentor. Leaders
should be aware that self-disclosure is always occurring, whether
consciously or subconsciously. They should use self-disclosure only
to meet the task-related needs of the group and only after thoughtful
consideration. When personal questions are asked, leaders need to
consider the motivation behind the question. Often clients are seeking
assurance that the leader understands and can assist them.
Leaders can be cotherapists. Cotherapy (also called coleadership) is
an effective way to blend diverse skills, resources, and therapeutic
perspectives that two therapists can bring to the group. It provides an
opportunity to watch adaptive behavior. A malefemale cotherapy team
may be especially helpful; it shows people of opposite sexes engaging in
a healthful, nonexploitative relationship.
Leaders are sensitive to ethical issues. As the group process unfolds,
the leader needs to be alert, always ready to perceive and resolve issues
with ethical dimensions. Typical situations with ethical concerns include:
Overriding group agreement. Group agreements give the group
definition and clarity and are essential for group safety. In rare
situations, however, it would be unethical not to bend the rules to
meet the needs of an individual. Sometimes the needs of the group
override courtesies shown to an individual. For example, if a member
becomes seriously ill and must miss sessions, other members may
want to express their concerns for the missing member in the group
even though they have agreed not to discuss absent members.
Informing clients of options. Even when group participation is
mandated, clients should be informed of options open to them.
For example, a member deserves the option to discuss with an
administrator a leaders behavior that the client finds inappropriate.
Preventing enmeshment. Leaders should be aware that the power of
groups can have a dark side. The need to belong is so strong that it
can sometimes cause a client to act in a way that is not genuine or
consistent with personal ethics. The leader needs to monitor group
sharing to ensure that clients are not drawn into situations that
violate their privacy or integrity; the leader is obligated to respect the
rights and best interests of individuals.
6-5

Acting in each clients best interest. It is possible that the group
collectively may validate a particular course of action that may not be
in a clients best interest. The leader is responsible for challenging
conclusions or recommendations that deny individual autonomy or
could lead to serious negative consequences.
PP 6-6
PP 6-7
Leaders handle emotional contagion. Anothers sharing can stir
frightening memories and intense emotions in listeners. In this
atmosphere, leaders are required to:
Protect individuals. The leader should guard the right of each member
to refrain from involvement, making it clear that each member has
the right to private emotions and feelings.
Protect boundaries. No one should be obligated to share intimate
details.
Regulate affect. The leader needs to modulate affect (emotionality),
always keeping it at a level that enables the work of the group to
continue.
Leaders work within professional limitations. Leaders should never
attempt to use techniques for which they are not trained or with
populations or in situations for which they are unprepared. When new
techniques are used or new populations are being served, leaders
should have appropriate training and supervision.
Leaders ensure flexibility in clients roles. Although it is natural for
members to assume certain roles (one client may naturally take on the
role of a leader, whereas another may assume the role of scapegoat),
individual members benefit from experiencing aspects of themselves in
different roles. Role variation keeps the group lively and dynamic.
Leaders avoid role conflict. Leaders should be sensitive to issues of dual
relationships. A leaders responsibilities outside the group that place him or
her in a different relationship to group participants should not be allowed to
compromise the leaders in-group role. For example, leaders should avoid
attending self-help meetings at which group members are present.
Leaders improve motivations. Motivation generally improves when:
Members are engaged at the appropriate stage of change.
Members receive support for change efforts.
The leader explores choices and their consequences with members.
The leader communicates care and concern for members.
The leader points out members competencies.
Positive changes are noted in and encouraged by the group.
6-6
TIP 41 Curriculum

PP 6-8
Leaders work with, not against, resistance. Resistance generally arises
as a defense against the pain that therapy and examining ones behavior
usually brings. In group therapy, resistance is at the individual and
group levels. The leader should have a repertoire of means to overcome
resistance that prevents success.
Leaders protect against boundary violations. Providing a safe,
therapeutic frame for clients and maintaining firm boundaries are
among the most important functions of the leader. The boundaries
established should be mutually agreed on and specified in a group
agreement or the ground rules. Boundary violations should be pointed
out in a nonjudgmental, matter-of-fact way.
Leaders maintain a safe, therapeutic setting:
Emotional aspects of safety. Members should learn to interact in
positive ways. They need to feel safe without blaming or scapegoating
others. If a member makes an openly hostile comment, the leader
should clearly state that members are not to be attacked.
Substance use. The presence of an intoxicated group member will
upset many members. The leader should ask the person who has
relapsed to leave the current session. After the person has left, group
members can explore feelings about the relapse and affirm their
abstinence.
Boundaries and physical contact. When physical boundaries are
breached in the group and no one in the group raises the issue, the
leader should remind the members of the terms of the agreement
and call attention to the questionable behavior in a straightforward
way. A leader should know the agencys policies regarding violent
behavior. Members should be allowed to opt out of activities that
involve physical contact.
Leaders help cool down affect. Leaders carefully monitor the level of
emotional intensity in the group, recognizing that too much too fast can
bring on extremely uncomfortable feelings that interfere with progress.
When intervening to control runaway affect, leaders should be careful to
support the genuine expressions of emotions that are appropriate for the
group and the individuals stage of change.
Leaders encourage communication within the group. Leaders primary
task is stimulating communication among group members, rather than
between individual members and the leader. Leaders can do this by
praising good communication, noticing a persons body language and
asking the person to express the feeling, and helping members know
that their contributions are important. Leaders should speak often
but briefly.
6-7

30 minutes
PP 6-9
PP 6-10
PP 6-11
Presentation: Concepts and Techniques
Interventions may be directed to an individual or the group. They can be
used to clarify what is going on, redirect energy, stop a process that is
not helpful, or help the group decide what should be done. A well-timed,
appropriate intervention has the power to:
Help a client connect with other people.
Discover connections between the use of substances and inner thoughts
and feelings.
Understand attempts to regulate feelings and relationships.
Build coping skills.
Perceive the effect of substance use on ones life.
Notice meaningful inconsistencies among thoughts, feelings, and
behavior.
Perceive discrepancies between stated goals and what is actually being
done.
To move away from the center stage, leaders can:
Build skills in members; avoid doing for the group what it can do for
itself.
Encourage the group to learn the skills necessary to support and
encourage one another. Too much or too frequent support from
the leader can lead to approval seeking, which blocks growth and
independence. Supporting one another is a skill that should develop
through group phases.
Refrain from overresponsibility for clients. Clients should be allowed to
struggle with what is facing them.
Group leaders have come to recognize that, when confrontation is
equivalent to attack, it can have an adverse effect on the therapeutic
alliance and process, ultimately leading to failure. A more useful way
to think about confrontation is pointing out inconsistencies such as
disconnects between behaviors and stated goals. Confrontation used this
way is part of the change process and part of the helping process. It helps
clients see and accept reality, so they can change accordingly.
6-8
TIP 41 Curriculum

PP 6-12
PP 6-13
PP 6-14
Transference means that people project parts of important past
relationships into present relationships.
Emotions inherent in groups are not limited to clients. The groups inevitably
stir up strong feelings in leaders. Countertransference is the group therapy
leaders emotional response to a group members transference. Examples
include:
Feelings of having been there. Leaders with histories of substance
abuse have an extraordinary ability to empathize with clients who abuse
substances. If that empathy is not understood or controlled, it can
become a problem if the group leader tries to act as a role model or
discloses too much personal information.
Feelings of helplessness when the leader is more invested in the
treatment than the clients are.
Feelings of incompetence because of unfamiliarity with culture and
jargon. The leader should ask clients to explain terms and expressions
that can be misunderstood.
The leader needs to manage all feelings associated with
countertransference. With the help of supervision, the leader can use
countertransference to support the group process.
Resistance arises as a clients subconscious defense to protect himself
or herself from the pain of self-examination and change. These processes
within the client or group impede the open expression of thoughts and
feelings or block the progress of an individual or group. The effective
leader will neither ignore resistance nor attempt to override it. Instead,
the leader helps the individual or group understand what is getting in the
way, welcoming the resistance as an opportunity to understand something
important for the client or the group.
Leaders should recognize that members are not always aware of their
reasons for resistance. They should explore what is happening and what
can be learned from it, not battle the resistance. Leaders may have
contributed to the resistance, and efforts need to be made to understand
the problem.
Strict adherence to confdentiality regulations builds trust. If the bounds
of confdentiality are broken, serious legal, personal, and professional
consequences may result. All group leaders should be thoroughly familiar
with Federal laws on confdentiality and relevant agency policies. Leaders
should warn clients that what they say in group may not be kept strictly
confdential.
Group leaders have many sources of information on a client, including
the clients employers and spouse. Leaders should clearly explain how
information from these sources may and may not be used in group.
6-9

Violations of confdentiality among members should be managed in the
same way as other boundary violations; that is, empathic joining with those
involved followed by a factual reiteration of the agreement that has been
broken and an invitation to group members to discuss their perceptions
and feelings.
PP 6-15
Professionals within the entire healthcare network need to become more
aware of the role of group therapy for people abusing substances. To build
the understanding needed to support people in recovery, group leaders
should educate others serving this population as often as opportunities
arise, such as when clinicians from different sectors of the healthcare
system work together on a case. Similar needs for understanding exist with
probation offcers, families, and primary care physicians.
It is common for a client to be in both individual and group therapy
simultaneously. The dual relationship creates both problems and
opportunities. Skilled counselors can use what they discover in group about
the clients style of relatedness to enhance individual therapy. In situations
in which one counselor sees a client individually and another treats the
same client in group, the counselors should be in close communication with
each other. They should coordinate the treatment plan, keeping important
interpersonal issues alive in both settings. The client should know that this
collaboration routinely occurs for the clients beneft.
Leaders should be aware of various medication needs of clients, the
types of medications prescribed, and potential side effects. The pregroup
interview for long-term groups should ask each group member what
medications he or she is taking and the names of prescribing physicians
so cooperative treatment is possible. (Consent forms for the sharing
of information should be signed when appropriate.) If an evaluation of
prescription medications is needed, counselors should refer the client
to a consulting physician working with the agency or to a physician
knowledgeable about chemical dependence. Attention needs to be paid to
medications prescribed for physical illnesses as well.
6-10
TIP 41 Curriculum

PP 6-16
PP 6-17
Confict in group therapy is normal, healthful, and unavoidable. It can
present opportunities for group members to fnd meaningful connections
with one another and within their lives.
Handling anger, developing empathy for a different viewpoint, managing
emotions, and working through disagreements respectfully are major
and worthwhile tasks for recovering clients. The leaders judgment and
management are crucial as these tasks are handled. It is just as unhelpful
to clients to let the confict go too far as it is to shut down a confict before
it gets worked through. The group leader must gauge the verbal and
nonverbal reactions of every group member to ensure that everyone can
manage the emotional level of the confict.
The leader facilitates interactions between members in confict and calls
attention to subtle, unhealthful patterns. Conficts within groups may be
overt or covert. The leader helps the group bring covert conficts into the
open. The observation that a confict exists and that the group needs to pay
attention to it actually makes group members feel safer. The decision to
explore the confict further is made based on whether such inquiry would
be productive.
Leaders should be aware that many conficts that appear to scapegoat a
group member are actually misplaced anger that a member feels toward
the group leader. When the leader suspects this situation, the possibility
should be forthrightly presented to the group.
Individual responses to particular conficts can be complex and can
resonate powerfully according to a clients values. After a confict, it is
important for the group leader to speak privately with members and
determine how each feels. Leaders often use the last 5 minutes of a
session in which a confict has occurred to give group members an
opportunity to express their concerns.
In any group, subgroups inevitably will form. Individuals will feel more
affnity and more potential alliance with some members than they feel with
others. One key role for the leader is to make covert alliances overt.
Subgroups can sometimes provoke anxiety, especially when a therapy
group comprises individuals who were acquainted before becoming group
members. Such connections are potentially disruptive. When groups are
formed, leaders should consider whether subgroups would exist.
When subgroups stymie full participation, the group leader can reframe
what the subgroup is doing. At other times a change in room arrangement
may be able to reconfgure undesirable combinations.
Subgroups are not always negative. The leader may intentionally foster a
subgroup that helps marginally connected clients move into the life of
the group.
6-11

PP 6-18
PP 6-19
TIP 41 identifes three types of disruptive behaviors:
Clients who cannot stop talking. When a client talks on and on, he or she
may not know what is expected in a group. At other times, a client may
talk more than his or her share because he or she is not sure of what
else to do. If group members exhibit no interest in stopping a compulsive
talker, it may be appropriate to examine this silent cooperation. Group
members may be avoiding examining their own past patterns of
substance abuse and forging a more productive future. When this motive
is suspected, the leader should explore what group members have and
have not done to signal the speaker that it is time to yield the floor. It
may also be advisable to help the talker find a more effective strategy for
being heard.
Clients who interrupt. Interruptions disrupt the flow of discussion in the
group, with frustrating results. The client who interrupts is often someone
new to the group and not yet accustomed to its norms and rhythms.
Clients who flee a session. Clients who run out of a session often are
acting on an impulse that others share. It would be productive in such
instances to discuss these feelings with the group and to determine what
members can do to talk about these feelings. The leader should stress
that the therapeutic work requires members to remain in the room and
talk about problems instead of attempt to escape them.
Sometimes, clients are unable to participate in ways consistent with group
agreements. They may attend irregularly, come to group intoxicated, show
little or no impulse control, or fail to take medications to control a co-
occurring disorder. Removing someone from group is serious and should
never be done without careful thought and consultation.
The decision to remove an individual is not one the group makes. The
leader makes the decision and explains to the group why the action was
taken. Members then are allotted time to work through their responses to
what is bound to be a highly charged event. Anger at the leader for acting
without group input or acting too slowly is common in expulsion situations
and should be explored.
6-12
TIP 41 Curriculum

PP 6-20
TIP 41 briefy addresses seven common problems in group:
Coming late or missing sessions. Sometimes leaders view the client
who comes to group late as a person who is behaving badly. It is more
productive to see this kind of boundary violation as a message to be
deciphered.
Silence. Nonresponsiveness may provide clues to clients difficulties with
connecting with their inner lives or with others. Special consideration
is sometimes necessary for clients who speak English as a second
language (ESL). Experiences involving strong feelings can be hard to
translate. When feelings are running high, even fluent ESL speakers
may not be able to find the right words to say what they mean or may be
unable to understand what another group member is saying about an
intense experience.
Tuning out. When clients seem present in body but not in mind, it helps
to tune into them just as they are tuning out. The leader should explore
what was happening as an individual became inattentive.
Participating only around the issues of others. Even when group
members are disclosing little about themselves, they may be gaining a
great deal from the group experience, remaining engaged on issues that
others bring up. To encourage a member to share more, a leader might
introduce the topic of how well members know one another and how well
they want to be known.
Fear of losing control. Sometimes clients avoid opening up because
they may become tearful in front of others. When this restraint becomes
a barrier, the leader should help them remember ways that they have
handled strong feelings in the past. When a client cries or breaks down,
the leader should validate the feelings and should concentrate on the
persons adaptive abilities.
Fragile clients with psychological emergencies. Because clients know that
the leader is bound to end the groups work on time, they often wait until
the last few minutes to share emotionally charged information. The leader
should recognize that the client has deliberately chosen this time to share
this information. The timing could be the clients way of limiting the groups
response and avoiding an onslaught of interest. The group should point out
this self-defeating behavior and encourage the client to change it.
Anxiety and resistance after self-disclosure. Clients may feel great
anxiety after disclosing something important. Leaders should assure
clients that people disclose information when they are ready and that
they do not have to reiterate the disclosure when new clients enter
the group.
6-13
5 minutes
Summary
The trainer:
session.
7-1
5 minutes
PP 7-1
Module 7: Supervision
Module 7 Overview
The goal of Module 7 is to provide participants with an overview of the skills
group therapy leaders need, the purpose and value of clinical supervision,
and necessary training. The information in Module 7 covers Chapter 7 of
Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment:
Group Therapy. This module takes 45 minutes to complete and is divided
into four sections:
Presentation: Training (15 minutes)
Presentation: Supervision (10 minutes)
Summary (15 minutes)
TIP 41 Curriculum

PP 7-2
15 minutes
PP 7-3
PP 7-4
The goal of Module 7 is to provide an overview of the skills group therapy
leaders need, the purpose and value of clinical supervision, and necessary
training. By the end of the session, you will be able to:
Identify training opportunities.
Appreciate the value of clinical supervision.
Presentation: Training
Many substance abuse treatment counselors have not had specifc training
and supervision in the special skills needed to be an effective group leader.
Common errors that counselors make include:
Impatience with clients slow pace of dealing with changes
Inability to drop the mask of professionalism
Failure to recognize countertransference issues
Not clarifying group rules
Conducting individual therapy rather than using the entire group
effectively
Failure to integrate new members effectively into the group
Training and education for group leaders working in the substance abuse
treatment feld can alleviate or eliminate such errors. Simultaneously,
additional training is becoming even more critical because the traditionally
separate felds of mental health and substance abuse counseling
increasingly overlap, requiring more and more cross-knowledge, and
because an ever-younger pool of clients is presenting with more cognitive
defcits, abuse issues, and co-occurring disorders.
A group leader for people in substance abuse treatment requires
competencies in both group work and addiction. Before leading a group, a
leader needs training in:
Theories and techniques. Theories may include traditional
psychodynamic methods, cognitivebehavioral modes, and systems
theory. Applications that pertain to a wide variety of settings and
particular client populations are drawn from these theoretical bases.
Observation. The observer can sit in on group therapy sessions, study
videotapes of group sessions (ordinarily followed by a discussion), or
watch groups live through one-way mirrors.
Experiential learning. The leader can participate in a training group offered
by an agency, become a member of a personal therapy group (these are
often process-oriented groups), or join in group experiences at conferences.
7-2 7-2
7-3

Supervision. Training is ongoing with groups under the supervision
of an experienced leader. Supervision in a group enables leaders to
obtain first-hand experiences and helps them better understand what is
happening in groups that they will eventually lead.
In group therapy with clients with substance use disorders, establishing and
maintaining credibility with all group members can be challenging. Leaders
not in recovery will need to anticipate and respond to group members
questions about their experience with substances and will need skills to
handle group dynamics focused on this issue. However, leaders in recovery
may tend to focus too much on themselves. Group leaders emotionally
invested in acting as models of recovering perfection are setting themselves
up for negative group dynamics.
The main issue is not whether the leader is in recovery. What matters most
is whether the leader is trained in group therapy and addiction treatment
and has good judgment and leadership skills. Helping the group explore
why the recovery status of the group leader is important can be discussed
when members raise the issue.
PP 7-5
National professional organizations are a rich source of training. Through
conferences or regional sessions, national associations provide both
experiential and didactic training geared to the needs of a wide range
of professionals, from the novice to the highly experienced counselor.
Professional organizations that provide a variety of training include:
American Group Psychotherapy Association (AGPA) has more than 4,000
members who provide professional, educational, and social support for
group counselors: http://www.agpa.org.
American Psychiatric Association has more than 35,000 U.S. and
international member physicians who work to ensure humane and
effective treatment for all persons with mental disorders:
http://www.psych.org.
American Psychological Association offers a certificate of proficiency
in the treatment of alcohol and other psychoactive substance use
disorders: http://www.apa.org.
American Society of Addiction Medicine (ASAM) educates health
professionals about addiction: http://www.asam.org.
Association for Specialists in Group Work (ASGW) is a division of the
American Counseling Association and was founded to promote high-
quality training, practice, and research: http://asgw.org.
7-4
TIP 41 Curriculum

PP 7-6
PP 7-7
10 minutes
PP 7-8
Association for the Advancement of Social Work with Groups (AASWG)
is an international organization that develops standards to refect the
distinguishing features of group work: http://www.aaswg.org.
NAADACNational Association for Addiction Professionals is the largest
organization for alcoholism and drug abuse professionals and offers
workshops, seminars, and education programs for members:
http://www.naadac.org.
National Association of Black Social Workers (NABSW) offers
conferences and mentoring programs to support the work of African-
American social workers: http://www.nabsw.org.
National Association of Social Workers (NASW) has developed practice
standards and clinical indicators, a credentialing program, continuing
education courses, and publications: http://socialworkers.org.
Many agencies mandate a certain number of trainings each year and
provide in-house training that draws on the resources of credentialed senior
management. Each State has a department of alcohol and drug abuse
services, and some States provide substance abuse training for group
therapy. Training in mental health issues is often available through the
mental health division of government agencies, professional associations,
and psychological and psychiatric organizations. Most colleges, universities,
and community colleges offer relevant courses.
Two Federal entities offer resources for training. The Substance Abuse and
Mental Health Services Administration (SAMHSA) provides a number of
resources, including the TIP Series and Technical Assistance Publications
(TAPs). Publications in these series can be ordered from the SAMHSA Store
at 1-877- SAMHSA-7 (1-877-726-4727) or at http://www.store.samhsa.
gov. Publications can also be downloaded from the Knowledge Application
Program Web site at http://www.kap.samhsa.gov. The SAMHSA Store also
provides a wealth of information on mental health issues. The National
Institute on Drug Abuse provides materials at http://www.nida.nih.gov.
Presentation: Supervision
Clinical supervision, as it pertains to group therapy, is best carried out
within the context of group supervision. Group dynamics and group process
facilitate learning by setting up a microcosm of a larger social environment.
The supervisor should be competent in several content areas, including
substance abuse treatment, group training, cultural competence, and
diagnosis of co-occurring disorders. A supervisor may be an administrator,
an in-house trainer, or a counselor from another agency.
The key to effective group therapy supervision is the development of the
supervisory alliance. In this working relationship, the counselor develops
7-5

skills in group analysis and refnes abilities to develop appropriate
treatment strategies. The supervisory alliance is needed to teach the
counselor the skills needed to lead groups effectively and to make sure that
the group accomplishes its purposes.
PP 7-9
PP 7-10
15 minutes
The supervisor should be able to assess the domains that leaders are
required to master. These include:
Clinical skills (from selecting prospective group members and designing
treatment strategies to planning and managing termination)
Comprehensive knowledge of substance abuse, which could entail broad
general knowledge of, or a thorough facility with, a particular field
Knowledge of the preferred theoretical approach
Knowledge of psychodynamic theory
Knowledge of the institutions preferred theoretical approaches
Diagnostic skills for determining co-occurring disorders
Capacity for self-reflection, such as recognizing ones own vulnerability
and ability to monitor and govern behavioral and emotional reactions
Consultation skills, such as the ability to consult with the referring
therapist, provide feedback, and coordinate both individual and group
treatment
Capacity to be supervised, including openness in supervision, setting
goals for training, and discussing with a supervisor ones learning style
and preferences
Summary
In this last session, the trainer:
Asks participants for feedback on the course in general and any
modules that they found particularly interesting.
If using feedback/course evaluation forms, asks participants to
complete forms before they leave.
Thanks participants for attending the training and encourages
them to explore further the issues raised during the training.
HHS Publication No. (SMA) 11-4664
Printed 2012

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